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Stomach and Duodenum—Mallory–Weiss Tear

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Stomach and Duodenum—Mallory–Weiss Tear

Concept

UGIB in a patient after forceful vomiting. The result of a linear tear in the mucosa of the gastric cardia.

Way Question May be Asked?

“A 23 y/o man presents to ED with hematemesis after binge drinking.” Pain should not be a prominent feature, if so, consider Boerhave’s syndrome. May see in patients with vomiting from other causes such as pancreatitis or chemotherapy.

How to Answer?

Resuscitate pt while doing focused H +P

History

NSAID/ethanol use History of PUD H. pylori treatment Portal HTN

Hiatal Hernia (tear usually in gastric cardia rather than at GEJ)

History of Violent retching

Remember your DDx of UGIB:

PUD, esophagitis, varices, Mallory-Weiss Tear,

Physical Exam

Check vital signs

Look for peritoneal signs (guarding, rebound)

Labs

Full laboratory panel including coags T +C

Management

Two large bore IV’s Large caliber NGT

Irrigate via NGT to estimate ongoing blood loss Correct coags

Resuscitate the pt IV H

2

blockers

Blood transfusion if unstable

EGD →identify and control bleeders r/o other pathology

heater probe, sclerotherapy, electrocautery Angiography → to diagnose bleeder Embolization of branches of left gastric Selective infusion of vasopressin

NO SENGSTAKEN–BLAKEMORE TUBES here

Surgery Indications

Over 6 U PRBC transfused Failure of EGD to stop bleeding

Failure of angiographic embolization (used in pts with severe comorbidities)

Surgical Treatment

Upper midline incision

Explore UGI (may see subserosal hematoma at GEJ along lesser curve of stomach)

Gastrostomy

Oversew of mucosal tear with absorbable, locking suture

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Can pack proximal and distal stomach with lap pads to locate bleeding source

Common Curveballs

EGD will not see mucosal laceration There will be evidence of perforation Stomach will be full of blood

EGD will pick up other pathology (change scenario) Endoscopic control/Angiographic control will fail Pt will have portal HTN

Sclerotherapy will result in esophageal perforation Pt will have had prior abdominal surgery

Tears will be in distal esophagus (may need left thora- cotomy and esophagotomy and then suture ligation)

May need to intubate pt with significant hematemesis before EGD (otherwise pt will aspirate)

Strikeouts

Jumping to angiography rather than EGD first Using Sengstaken-Blakemore tube

Not resuscitating the pt

Mistaking for Boerhave’s syndrome

Performing any type of anti-ulcer surgery (V +P, A+V, subtotal gastrectomy)

Not looking for other pathology on EGD Trying to do any of the above with a laparoscope

Strikeouts 117

Part 2.qxd 10/19/05 2:52 AM Page 117

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